Therapeutic Communication

The DO’s of Therapeutic Communication

- Use open ended questions
- Use therapeutic silence
- Use therapeutic touch
- Remain focused on the client
- Present reality
The DON’Ts of Therapeutic Communication
- Ask WHY
- Dismiss a client’s feelings
- Give false reassurance
- Give personal opinion
- Pass it off to someone else
- Argue with the client
- Make assumptions

Open-ended questions
● Provides the client with an opportunity to express their thoughts

● Encourages communication

● Focuses on client centered responses

● Allows the client to be in charge of the direction of the conversation.

Practice Question
A widower is complaining of insomnia, shortness of breath, extreme anxiety, and a sense of impending doom. Which
response by the nurse is most appropriate?

A. “Just relax. You’re in a safe place now. You have nothing to worry about.”
B. “Has anything happened recently, or is there anything in the past that could have triggered these feelings?”
C. “The medication that I have given you will help decrease these feelings of anxiety.”
D. “Why don’t you take some deep breaths to help you calm down?”

Answer: B
Choice B is correct. This response reassures the client and provides an opportunity to gain insight into the root of the
client's anxiety.

Choice A is incorrect. Telling the client he has nothing to worry about dismisses the client's feelings and only gives him
false reassurance. By indicating to the client that there is no cause for anxiety, the nurse is thereby devaluing the client's
feelings. By doing so, the nurse may inadvertently discourage the client from further verbalizing their feelings, as the client
believes they will only be subsequently downplayed or ridiculed.

Choice C is incorrect. Simply medicating a client and instructing them to calm down doesn't allow the client to verbalize
their feelings, which is necessary for both the client and the treating health care provider (HCP) to understand and
ultimately use to resolve the underlying cause of the anxiety.

Choice D is incorrect. Telling the client to take some deep breaths to help calm down implies that the nurse knows what
is best and that the client is incapable of any self-direction. This type of nontherapeutic communication nurtures the client
into a dependent role by discouraging independent thinking and should therefore be avoided.
Therapeutic Silence
● Effective for clients in the acute phase of severe depression
● Makes no demands of them
● Simply be with them

Practice Question
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the
patient's son is silently holding her hand and praying. Which of the following should be the nurse’s initial action?

A. Continue preparing for the procedure in the room.

B. Notify the chaplain.
C. Leave the room quietly and come back after 15 minutes to change the client’s dressing.
D. Ask the son if he wants the nurse to join in prayer.
Answer: C
Choice C is correct. The nurse should respect the client and her son in their moment of prayer and should not impose on
them. The nurse's best action is to leave the room and come back when they are finished praying.

Choices A, B, and D are incorrect. It is inappropriate for the nurse to continue preparing for the procedure (Choice A). The
nurse should respect the client and her son's need for privacy during the prayer. The most appropriate action of the nurse
is to leave the room momentarily. Unless requested by the client, the nurse should not inform the chaplain (Choice B) or
any other person. Asking the son if she can be allowed to join the prayer (Choice D) is inappropriate. The nurse should
respect their right to privacy and should not impose on the client.

Therapeutic Touch
● Hold the client's hand
● Place your hand on their shoulder
Remain focused on the client
● Focus should be on THEM
○ Not yourself
○ Not examples of other clients
● Present reality
○ Do not endorse any hallucinations or delusions
○ Focus on what is really occurring
■ Right here, right now!

Practice Question
The nurse is caring for a client who is experiencing psychosis. The client states, "You all are trying to kill me!" Which
of the following responses would be most appropriate for the nurse to make to the client?

A. “What you are experiencing is not real.”

B. “Are you hearing voices?”
C. "You are safe here, please be calm.”
D. “What makes you think we are trying to kill you?”
Answer: D
Choice D is correct. A client experiencing psychosis does not exhibit a rational thought process and may have impaired
reality testing. If the client is paranoid, the nurse should attempt to understand the paranoia as the patient has likely
misconstrued an action.

Choices A, B, and C are incorrect. While it is essential to inquire if the client is experiencing auditory hallucinations and
reassure them that their thought is not real, it is a priority to understand the delusion by inquiring about its root.
Reassuring safety is important but will not inquire about a patient’s current thought process.

The DON’Ts of Therapeutic Communication

- Ask WHY
- Dismiss a client’s feelings
- Give false reassurance
- Give personal opinion
- Pass it off to someone else
- Argue with the client
- Make assumptions
Never ask WHY
● Why statements are not therapeutic.
● This points the finger at the client and makes them feel as if it is their fault
they are having these feelings.
● Asking why someone feels the way they do invalidates them
● It will not promote the open and honest communication that is necessary for
a therapeutic environment.

Practice Question
Which of the following statements would be effective therapeutic communication for a client who is struggling with
severe depression?

A. “Great work today in group therapy Steve, you were really talkative today!”
B. “I’d like to just sit with you for a while Steve.”
C. “Are you feeling sad today, Steve?”
D. “Why are you feeling depressed today Steve?”
Answer: B
Choices B is correct. The therapeutic communication technique of silence is very effective with patients in the severe
phase of depression. These patients have very little, if any, energy. Making absolutely no demands or requests of them,
but being present and supportive, is often the best way to begin a therapeutic relationship.

Choice C is incorrect. This is a close ended question that will not elicit any further conversation from the client.

Choice A is incorrect. Although this sounds like an encouraging thing to say, compliments are not always therapeutic in
patients suffering from depression. They have very little to no self-esteem and often take compliments the wrong way.
Even though you meant to encourage Steve by telling him he was talkative, he will likely take this as saying he was talking
too much and should be quieter next time.

Choice D is incorrect. “Why” statements are not therapeutic. This points the finger at the client and makes them feel as if
it is their fault they are having these feelings. Asking ‘why’ someone feels the way they do invalidates them, and will not
promote the open and honest communication that is necessary for a therapeutic environment.

Never dismiss a client's feelings

● Important to make sure the client knows they are heard.
● Their feelings should be validated.

● “You have nothing to worry about”

● “It will all be okay”
● “Others have it worse off than you do”
● “I’ll just give you some medication so you can relax”
Never give false reassurance
● These are promises you can’t always keep
● Don’t give you any chance to explore the client's feelings.

● “Nothing bad can happen to you here”

● “It will all be alright”
● “You don’t need to worry you’re safe here”

Practice Question
The RN is caring for a family who just found out that their newborn baby has tetralogy of Fallot. The parents state,
"We can't believe our baby is going to die!" Which of the following statements by the RN is most appropriate?

A. “Yes, that is so sad. What can I do to help you?”

B. “Your baby will be fine! This is not so serious.”
C. “Tetralogy of Fallot can be surgically repaired. Let’s talk more about what you can expect.”
D. “Well, at least you get to spend time with your baby now. Some people don’t even get that.”
Answer: C
Choice C is correct. This statement does not support that the baby will die, but provides factual information about the
treatment plan for the defect and leads into a more detailed conversation about what the parents can expect. It is clear
that they do not fully understand tetralogy of Fallot (TOF) and the treatment options, so education is very important for
these parents.

Choice A is incorrect. This is not a therapeutic statement, as it is not necessarily true that the baby is going to die. The
nurse should not validate this fear, rather the nurse needs to provide further education to help the family understand what
to expect.

Choice B is incorrect. The nurse should not invalidate the parent's fears. TOF is a very serious heart defect, so telling the
parents that the baby will be fine may not be true. It is important to provide factual education to the parents so that they
understand their child's cardiac defect.

Choice D is incorrect. This statement is neither helpful nor accurate. The nurse should not say this.

Never give your personal opinion

● It’s not your place!
● What you would do, what your friend did, what your previous clients have
done….. Doesn’t matter!
○ It is THIS client’s experience
○ Stay focused on THIS client
Practice Question
The nurse is speaking with her patient who is undergoing chemotherapy treatment. The patient states, "My friend
beat cancer using complementary therapies; I think I should try that too." Which of the following responses from the
nurse is most appropriate?

A. "Complementary therapies are not safe with your chemotherapy."

B. “I would be desperate if I had cancer too.”
C. "Let us go get your healthcare provider so that we may discuss it with him."
D. “Tell me more about what you mean when you say complementary therapies.”

Answer: D
Choice D is correct. This is the most therapeutic statement. Effective communication always begins with an "open"
statement. It addresses the question asked by the client and will lead to further discussion. The nurse should explore
what therapies the client is interested in talking about first, so that she may better help the client when discussing the
therapies with the healthcare provider.

Choice A is incorrect. The nurse should be aware of therapeutic communication strategies. This statement is neither
accurate nor therapeutic. Many complementary therapies may be used, along with chemotherapy, and may not be
detrimental.

Choice B is incorrect. This statement is inappropriate. Implying that the patient is desperate is not therapeutic.

Choice C is incorrect. The healthcare provider always needs to be aware of complementary therapies that the client
is considering, but this should not be the nurse's first response. Such initial statements do not encourage open and
honest discussion with the patient. The nurse should first ask the patient to tell her more about the therapies she is
interested in before having the patient speak with the healthcare provider.
Pass it off to someone else
● Often, you may need to involve other team members!
● BUT - we don’t want to shut the client down by saying they need to ask
someone else…. It just doesn’t come off very well!
● Therapeutic statements will stay open-ended!

● “Let’s ask the healthcare provider”

● “You should discuss that with your family”
● “Sounds like a question for the social worker”

Argue with the Client

● Even if what they are saying is not true, arguing with them is not therapeutic.
● Especially important with mental health clients
○ Don’t endorse delusions/hallucinations
○ DO present your own reality
Practice Question
Which of the following nursing interventions are appropriate for a manic patient experiencing delusions of
grandeur?

Select all that apply.

A. Refrain from talking excessively about their delusion

B. Set boundaries
C. Enforce three meals a day
D. Argue that their delusions are not your reality
E. Utilize therapeutic touch

Answers: A and B
Choices A and B are correct. It is essential to refrain from talking much about the delusions that your manic patient is having. Delusions of
grandeur, such as the patient thinking they are god, come from a need for them to feel necessary and proper about themself. You need to support
the patient’s confidence in a realistic way. By refraining from talking excessively about the delusion, you are not supporting its reality, which is
therapeutic for the patient (Choice A). Setting boundaries and limits are incredibly crucial for the manic patient. These patients can be incredibly
manipulative and by setting limits, you will be helping them come back down to reality. Consistency is also key to these boundaries. For example, if
you make a rule that lights must be off at 10:00 pm each night, this rule should be followed every single night without exception (Choice B).

Choice C is incorrect. Enforcing three meals a day will not work for the manic patient. They are too busy to sit down for a large meal and will end
up just forgetting to eat. This can lead to severe malnutrition and dehydration. It is essential to provide the patient with finger foods and stay with
them while they walk and eat. Keep them calm and try to maximize the calories that they are getting instead of trying to enforce sitting through
three meals a day.

Choice D is incorrect. It is not therapeutic to argue with a manic patient. These patients are very manipulative and argumentative. They will fight
back and their behavior will escalate. It is essential to help guide them towards reality by setting boundaries and letting them know their delusion
is not your reality, but you should never argue.

Choice D is incorrect. It is not appropriate for clients who are experiencing delusions or hallucinations as it can startle them and diminish the
therapeutic relationship.